What They're Not Saying

The trick in understanding any contentious public debate is to figure out what's being left out of the discussion. What, for example, is the assumption that's so obvious that no one thinks to bring it up? More often than not, when you've located that assumption, you've found the secret core of the argument -- the part that everyone's really fighting over and no one can bear to mention.

Take the current battle over drug prices. Critics say prices are too high; the industry says it needs to finance research. Critics say too much revenue from drugs is poured into profits; the industry says that without profits, there will be no innovation. Critics counter that there's already not enough innovation. You've heard it all before. But what's the part that gets left out?

Here's one possible answer: The critique of prices is based on some powerful, but messy and ill-examined, assumptions about equality and healthcare and the structure of society. Behind the argument for lower prices, there's another argument that runs something like this:

A society like ours needs some basic forms of equality -- equal access to education, equal access to healthcare, equal treatment under the law. In fact, we've never achieved any of those goals. The rich live longer than the poor; they're healthier; they go to better schools -- or if they go to the same schools, they get better results out of them. All of those failures in equality are disruptive to society, and the disruptions we anticipate from expensive new drugs are even worse because they make inequality so obvious and so painful. We don't want this to become an openly discussed issue, because it looks impossible to resolve. Therefore, despite our considerable commitment to free-market capitalism, we think your prices should come down to postpone the day of reckoning.

I understand that there's more than one point of view behind the cheaper-drug movement, but it seems to me that the line of thinking I've just described truly underlies much of the criticism I've heard of big pharma in the past few months. And it shows why the argument over prices resists conventional economic analysis -- and why it's not likely to go away.

Who should have access to expensive drugs and treatments? Anyone who could reasonably benefit by them? Anyone for whom they're a cost-effective alternative to hospitalization, long-term care, or death? Just those who can afford to pay for them? These are questions we ought to be addressing. Society can't -- or won't -- provide everything to everybody. On the other hand we need to be realistic; in the long run, we probably can't prevent people with resources from getting what they choose. The government can set price caps. It can refuse to license drugs deemed inessential -- though that will simply drive innovation overseas. As long as there's economic inequality in our society, any form of for-profit healthcare will be profoundly disruptive, pointing out the contradictions in our way of life more clearly than almost anything else can. We can ignore mansions and fine cars; but when one citizen can buy extra years of life and another can't, we notice. And why not? Mansions and cars are just a way of keeping score; extra years of life change the playing field.

Of course, changing the playing field is what the pharma industry is about. The history of drugs is the history of inevitabilities overturned -- death averted, life extended, pain relieved. That history is far from over. There are battles to win -- and some to lose, as well. In the end though, the point is to ensure that tomorrow is better than today. That, after all, is an inequality all of us are willing to fight for.